Insomnia is one of the most common health concerns among adults. It is a common sleep disorder characterized by chronic dissatisfaction with sleep quality or quantity associated with difficulty falling asleep, frequent nighttime awakenings with difficulty returning to sleep, or awakening earlier in the morning than desired. All these can lead to daytime impairments, such as sleepiness or difficulty concentrating.
Insomnia is considered to be the most common sleep disorder. Studies show that around 30% to 40% of American adults occasionally experience insomnia symptoms. However, if someone is concerned about their sleep and experiencing these symptoms, it is advised to discuss them with a health professional for proper diagnosis and treatment.
Insomnia Symptoms
Insomnia exists very commonly and studies have shown an increase in insomnia symptoms during the novel coronavirus (COVID-19) pandemic. According to the American Psychiatric Association (APA), a third of adults report some insomnia symptoms.
These symptoms include various sleep-related difficulties which can result in feeling fatigued during waking hours leading to impaired attention and memory. Studies show that insomnia has the potential to affect behavioral health and cause irritability, hyperactivity, or aggressiveness, especially in children.
Some of the symptoms are mentioned below:
- Difficulty falling asleep
- Difficulty staying asleep
- Early morning waking
- Feeling tired during the day
- Problem with concentration or memory
Types of Insomnia
Two types of insomnia are mainly observed depending on the duration of the symptoms. These are acute insomnia and chronic insomnia.
Acute insomnia:
In acute insomnia, sleep difficulties may last for a few days or weeks but not more than three months. It can be caused due to some external reason or life stressor like like divorce, death of a loved one, rejection, failure, or a major illness. It can be classified as chronic insomnia if it persists for multiple months.
Chronic insomnia:
In chronic insomnia, a person may experience sleeping difficulties for at least three days per week that persist for more than three months. It is observed that people with chronic insomnia often feel distressed about their inability to sleep as it can cause daytime sleepiness. These symptoms are severe and can affect academic performance as well as their social or family life.
The sleep disorder of insomnia is principally classified as either acute or chronic insomnia. However, some other characteristics are used to define different ways in which insomnia can be experienced. This helps in better categorization and analysis.
Sleep-onset insomnia:
In sleep-onset insomnia, a person experiences difficulty falling asleep whenever they attempt to initiate sleep. This may happen as a result of caffeine use, mental health symptoms, or other common insomnia triggers. Due to a lack of sleep, a person may experience sleepiness the next day during the daytime.
Maintenance insomnia:
Sleep maintenance insomnia means the inability to stay asleep throughout the night. In this, a person consistently wakes up many times or at least once during the night and finds it difficult to get back to sleep for at least 20-30 minutes. This fragmented sleep may decrease both sleep quantity and quality. Studies show that this type of insomnia might relate to underlying health and mental health symptoms.
What is the difference between primary and secondary insomnia?
Insomnia is associated with several medical and psychiatric disorders that include chronic pain and clinical depression. Studies show that effective treatment of the underlying medical conditions can correct sleep disturbance. Generally, insomnia can be classified as primary or secondary insomnia. This classification depends on whether insomnia is caused by an underlying condition or not.
| Primary Insomnia | Secondary Insomnia | |
|---|---|---|
| 1. | It is a type of inherent sleep dysfunction that is not affected by any environmental factors. | It is an acquired condition that can be caused by an external factor or an underlying cause. |
| 2. | Genetic predisposition is the predominant factor leading to primary insomnia. | Many factors can lead to secondary insomnia such as stress, medication, pain, substance use, or a health condition. |
| 3. | Less common | More common |
| 4. | It may lead to paradoxical insomnia which is a subtype of chronic insomnia. | It is mostly reversible and may lead to some serious mental health conditions such as depression and anxiety. It can also cause cardiovascular complications if persists for a longer duration. |
Primary Insomnia
Primary insomnia is a sleep disorder characterized by difficulty falling asleep, staying asleep, or non-restorative (unrefreshing) sleep. This can lead to daytime fatigue and irritability. There are three subtypes of primary insomnia:
- Idiopathic insomnia: Insomnia without an identifiable cause.
- Stress-related insomnia: Insomnia triggered by mild stressors.
- Sleep state misperception (SSM) or paradoxical insomnia: Feeling of insomnia despite getting enough sleep.
Symptoms of primary insomnia may include:
- difficulty falling asleep at night
- difficulty staying asleep, with frequent awakenings during the night
- waking up too early in the morning and not being able to go back to sleep
- non-restorative sleep, where you do not feel refreshed upon waking
- daytime effects such as fatigue, daytime sleepiness, irritability, or difficulty concentrating
- increased worries or anxiety about sleep
Secondary Insomnia
Studies show that secondary insomnia is more common than primary insomnia. This condition is caused by some other external factors. It occurs as a side effect or symptom of various factors such as a medical condition, psychological condition, sleep disorder, or substance use (caffeine, alcohol, or tobacco).
Some of the underlying causes of secondary insomnia are mentioned below:
- Chronic pain
- Asthma or other breathing problems like sleep apnea
- Depression and other mental disorders
- Certain medications or drugs, including caffeine and tobacco
- An overactive thyroid
- Dementia and Alzheimer’s Disease
- Heartburn
- Hypertension
Symptoms of secondary insomnia may include:
- Feeling of fatigue
- Excessive daytime sleepiness
- Decrease energy, motivation, or initiative
- Difficulty concentrating
Causes of Insomnia
Insomnia does not have a single cause, it is a condition that involves many factors. National Sleep Foundation has defined some causes that can contribute to insomnia.
Some of these causes are mentioned below:
-
Genetics :
Studies show that 30-35% of people experience insomnia symptoms. This condition can be influenced by genetics and seems to run in families. -
Medical conditions :
Certain health problems can contribute to insomnia by disrupting the ability to sleep. This includes temporary illnesses like minor infections or injuries, or chronic conditions like acid reflux or Parkinson’s disease (neurological condition). Some other conditions may also be affected such as arthritis, asthma, chronic pain, and sleep apnea. -
Psychiatric condition :
It has been observed that half of the people with insomnia symptoms also have at least one other psychiatric condition such as depression, anxiety, schizophrenia, attention deficit hyperactivity disorder (ADHD), and bipolar disorder. -
Life changes :
There are some other temporary factors that can cause insomnia such as jet lag, sleeping in an unfamiliar place, and change in working schedule (especially happens with shift workers). Brief or temporary changes are often factors, including jet lag, sleeping in an unfamiliar place, or adjusting to a new work schedule (especially shift work). -
Habits and routine :
Unhealthy sleep habits and consumption of caffeine can also contribute to insomnia. It is important to maintain sleep hygiene for comfortable and quality sleep.
Risk factors for Insomnia
As insomnia does not have a single cause but several factors can put a person at a greater risk of experiencing insomnia.
Studies show that insomnia is more common in vulnerable patient groups, including active military personnel and veterans, patients with coexisting psychiatric and medical disorders, those in life transitions such as menopause, and elderly persons.
- Just before, during, and after menopause
- Older age
- Sedentary lifestyle
- Pregnancy
- Medical conditions like diabetes and chronic pain
- People who use alcohol
- Mood disorders including depression and anxiety
- Having an immediate family member with insomnia
Everyone who has one or more of these risk factors does not need to have insomnia. Therefore, it is important to consult a healthcare provider for a proper diagnosis.
Insomnia Treatment
Studies show that sleep allows the brain and body to slow down and engage in the process of recovery. Therefore, it is important to get enough sleep for the recovery process. It has been observed that current treatment therapies are highly effective against insomnia.
Acute insomnia can be treated using some sleep hygiene strategies such as keeping consistent wake and sleep timing, avoiding stimulating activities before bed, and shutting down electronic devices 30 to 60 minutes before bed. These strategies help in getting proper sleep and often alleviate sleep problems completely.
It is important to use these strategies to prevent insomnia symptoms because these strategies are not as effective in reversing sleep problems. It is recommended to prevent insomnia from becoming worse and consult a doctor to treat the symptoms as soon as insomnia is detected.
The interventions focus on psychological treatment of insomnia which includes cognitive-behavioral techniques, certain sleep restrictions, and sleep hygiene strategies. There are some guidelines published by the American Psychological Association (APA) that are followed while treating insomnia.
APA guidelines for the treatment of insomnia include:
- Treat the underlying cause
- Sleep hygiene
- Cognitive Behavioral Therapy
- Medication
- Alternative treatments such as meditation, yoga, and acupuncture
- Exercise
- Supplements
Cognitive behavioral therapy (CBT) is usually recommended as the first treatment for people with insomnia. It is an effective treatment strategy because it helps in controlling negative thoughts and actions that keep a person awake. The behavioral part of CBT helps in learning good sleep habits and stopping behaviors that affect sleep quality.
Insomnia Diagnosis
It is important to consult a doctor if difficulty in sleeping occurs for 3 or more nights a week and lasts for 3 months or longer. The doctor analyses the history of the patient, medical and psychiatric conditions, and substance use for accurate diagnosis.
Diagnosis of insomnia includes:
- Careful history and physical exam
- Bloodwork to exclude anemia, hyperthyroidism, B12 deficiency, magnesium deficiency, hormone imbalance, anemia, and other medical causes of anemia
- Neuroimaging if indicated
- Chest x-ray and oxygen saturation if suspected hypoxia
Differential Diagnosis of Insomnia
Insomnia is a most common sleep disorder that affects millions of people. It has been defined as both a symptom and a disorder that is important to treat to perform daily activities attentively. Therefore, it is crucial to differentiate insomnia from other diseases that cause sleep difficulties. Treatment guidelines are defined for people who meet the criteria for insomnia disorder rather than other diseases with insomnia symptoms. Differential diagnosis for insomnia include:
- Normal variants
- Sleep disorders
- Circadian rhythm sleep disorder
- Jet lag
- Delayed sleep-wake phase disorder (night owl)
- Advanced sleep-wake phase disorder (early bird or lark)
- Shift work sleep disorder
- Non-24-hour sleep-wake syndrome
- Irregular sleep-wake rhythm disorder
- Obstructive sleep apnea
- Movement disorders
- Restless legs syndrome
- Periodic limb movement disorder
- Circadian rhythm sleep disorder
- Narcolepsy
- Substance/medication-induced sleep disturbances
Differential diagnosis helps in understanding the reason for insomnia symptoms. This diagnosis process may involve a physical exam, sleep study, and review of sleep habits.
DSM 5 criteria for insomnia
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision (DSM-5-TR), symptoms must be present at least 3 days per week for at least 3 months for chronic insomnia, or fewer than 3 months for short-term insomnia. DSM-5 criteria for insomnia disorder include:
- Dissatisfaction with sleep quality or quantity associated with one or more of the following symptoms:
- Difficulty initiating sleep
- Difficulty maintaining sleep
- Early morning awakening with inability to return to sleep
- Sleep disturbances affect social, occupational, educational, academic, behavioral, and other important areas of functioning.
- Insomnia should not occur exclusively during another sleep-wake disorder such as narcolepsy (breathing-related sleep disorder), a circadian rhythm sleep-wake disorder, or a parasomnia.
- Insomnia should not explained by a coexisting mental disorder or a mental condition.
- Insomnia should not be attributed to the physiological effects of a substance, such as drug abuse or medication.
Insomnia Duration
The duration of insomnia symptoms helps differentiate between ‘acute’ and ‘chronic’ insomnia. In chronic insomnia, a person may experience sleeping difficulties for at least three days per week that persist for more than three months. While in acute insomnia, sleep difficulties may last for a few days or weeks but not more than three months.
Treatment and behavioral changes can help shorten the duration or sometimes completely alleviate the symptoms. It is important to get proper sleep according to the recommended hours.
Recommended hours of sleep according to age:
- Newborn (0–3 months) – 14–17 hours
- Infant (4–12 months) – 12–16 hours per 24 hours (including naps)
- Toddler (1–2 years) – 11–14 hours per 24 hours (including naps)
- Preschool (3–5 years) – 10–13 hours per 24 hours (including naps)
- School-age (6–12 years) – 9–12 hours per 24 hours
- Teen (13–18 years) – 8–10 hours
- Adult (18–60 years) – 7 or more hours per night
- Adult (61–64 years) – 7–9 hours
- Late adulthood (65 and above) – 7–8 hours
Complications of Insomnia
Studies show that if insomnia persists for a longer duration, it can lead to sleep deprivation. This condition is concerning because it can cause daytime sleepiness, which can be dangerous if someone is driving or doing tasks that require alertness and attention.
Sleep deprivation can also increase the risk of certain medical conditions:
- Depression
- Anxiety
- High blood pressure (hypertension)
- Heart attack
- Stroke
- Type 2 diabetes
- Obesity
Complications of Chronic Insomnia?
Insomnia can disrupt daily life activities and can affect a person mentally as well as physically.
Complications of insomnia include:
- Increased risk of cancer
- heart disease
- Stroke
- Anxiety
- Depression
- Cognitive decline
- Other mental illnesses
How to Prevent Insomnia
Some of the causes of insomnia can be prevented while others can happen for reasons that are not well understood. Certain things contribute to enhancing sleep quality. Studies show that stress and anxiety are potent sleep slayers. Therefore, it is important to avoid those activities that increase the risk of depression and anxiety.
Along with avoiding anxiety or depression triggers, some certain habits or behaviors help in better sleep:
- Try to maintain the same sleep-wake schedule, even on weekends.
- Create a relaxing bedtime routine that prepares you to sleep.
- Dim the lights and avoid using electronic devices an hour before bedtime.
- Get regular physical activity like walking and other low-impact exercises.
- Limit your caffeine and alcohol intake.
- Don’t eat heavy meals before bed.
- Avoid nicotine.
It is important to create a consistent bedtime ritual as this sends a signal to the brain and body that it is time to sleep.
Supplements for Insomnia
Herbal and natural supplements have gained popularity as alternative treatments for insomnia and other sleep disorders due to their perceived safety and potential effectiveness in improving sleep.
Studies show that certain supplements such as valerian, hops, and melatonin can effectively improve sleep quality and reduce insomnia symptoms through modulation of neurotransmitter systems and regulation of sleep-wake cycles.
Supplements for insomnia are generally considered safe, but in some cases can cause serious adverse effects associated with kava and potential interactions with prescription medications. It is advised to consult a healthcare provider before starting supplements for proper prescription and dosage details.
Some of the natural and herbal supplements for insomnia are mentioned below:
- Valerian
- Hops
- Kava
- German chamomile
- Tart cherry
- Tryptophan
- Theanine
- Melatonin
- Magnesium
- Zinc
FAQ
How long does Insomnia last?
Short-term insomnia is insomnia that you have for under three months. Chronic insomnia lasts more than three months.
The duration of insomnia depends on the cause of insomnia which can vary widely and can change, and shift over time. It is important to consult a healthcare provider to understand the ways to limit how it affects you.
How to Help Insomnia during Pregnancy?
Insomnia is common during pregnancy, especially in the first and third trimesters. This does not affect the baby’s development, but getting the right amount of sleep is important for overall well-being.
Some of the lifestyle changes mentioned below that could help during pregnancy:
- Eating a balanced diet
- Maintaining a consistent sleep schedule
- Practicing relaxation techniques such as meditation during the daytime. It will help relax the mind and contribute to quality sleep
Should I get treatment for Insomnia?
It is important to get enough sleep for a healthy lifestyle. Insomnia can affect an individual mentally and physically. It can make them feel tired, depressed, and irritable. Within a few days, untreated insomnia can cause severe psychiatric symptoms and impairment of social and occupational functioning.
